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Sunday, March 27, 2016

Chronic pain
topics trending on social media have increased with the release of the National
Pain Strategy (NPS) and the CDC Guidelines for Prescribing Opioids. Having
submitted comments on both drafts, I felt it was time to express my personal
opinions. There are vast differences between the two, even though the “CDC Guidelines” are specifically mentioned at the conclusion of the NPS report.

Overall, the checklist is not
difficult to understand and physicians will be more likely to use it. Where I
do not comment, assume it to mean I don’t see any reason to mention it.

Good Stuff:

·“For primary care
providers treating adults.” - Primary care physicians need guidelines by
government agencies so they do not fear retaliation by the DEA. Not all
patients living with persistent pain require supervision by a pain specialist; in
fact, there aren’t enough pain physicians to meet the needs of over 100 million
Americans living with chronic pain.

·“Known risk
factors” – Important assessment.

·“Prescription drug monitoring program” (eleven states do not have a PDMP) – You can read what I think about medication safety on my website. PDMPs are good for identifying signs of drug diversion or abuse,
which protects responsible people, but will physicians who treat patients with
conditions that cause chronic pain, i.e., pain physicians or rheumatologists be
singled out? And, how will this affect patient care in states without a PDMP?

·“Behavioral
treatment” – This piece is often difficult for physicians to discuss with their
patient’s, and vice versa. However, there is evidence that shows our behavioral
response to pain makes a difference in our ability to cope with the fall of of living with chronic pain, and how we respond to it mentally and emotionally can affect our pain
intensity. (This does not mean it treats the pain source directly, however.)

· “Schedule initial reassessment within 1– 4
weeks.” – This should be done any time a new medication is started, including non-opioids
that affect the central nervous system.

·“Assessing pain
and function using PEG scale” – This one gets a mixed review. Relieving pain,
decreasing the intensity to improve quality of life is the reason we seek pain
care. However, quality of life should be assessed according to what that means
for each individual patient. For instance, a diseased spine or joint is not going
to function better despite pain relief. Q1 is difficult because it relates to an acute pain scale, which is not helpful for assessing chronic pain, especially in a person with more than one pain condition. Q2 reverts back to my comments on changing behaviors. Enjoyment of life is not affected by opioids, it is affected by developing healthy coping skills as is the truth for any chronic illness. Enjoyment of life fluctuates for everyone. Q3 Improving endurance, i.e. activity, cannot be achieved without therapies that are often capped by Medicare and is not based on patient outcome. And, easing pain will not necessarily result in increased activity. Overall, asking a patient to make their own assessments is important, but placing an arbitrary number (30% improvement) is punitive. Many factors, life situations, can cause the numbers to fluctuate. One cannot assume status quo for chronic pain anymore than they can assume blood sugars will remain constant in treatment of diabetes.

Bad Stuff

·“Benefits of
long-term opioid therapy for chronic pain not well supported by evidence.” –
Describe evidence? Anecdotal reports from physicians who specialize in pain
medicine are evidence (but they were not represented in the “Core Group” of
experts). If they are referring to research, there is no evidence to suggest
opioids don’t work for long-term pain care.

·“Schedule
reassessment at regular intervals (≤ 3 months)” – This guideline is not
appropriate for patients who do not need advanced pain care. Patients who have been on the same opioid dose for years do not require such close observation. Many patients, particularly the elderly, do not have the ability to see the doctor this
frequently, nor is the physician available. To put an absolute time interval (without
cause) puts an unnecessary burden on the physician, patient, and insurance,
including Medicare, and drives up healthcare costs. This is a total disregard for common sense.

·“Urine drug
screens.” I am not against them when there are signs of abuse. (Perhaps the checklist should include assessment of those behaviors.) However, using
drug screens to assess risk without probable cause is offensive for several
reasons: they are accusatory (guiltily until proven innocent), they are
humiliating, they are not consistently accurate, and they are not always
covered by insurance, which is discriminatory against folks who can’t pay. Innocent people are being tortured by inaccurate results, while drug testing companies are making a killing, sometimes literally.

The Ugly

·“NON-OPIOID
THERAPIES Use alone or combined with opioids, as indicated:” – Suggesting long-term
use of NSAIDs is not safe, and there is evidence to suggest this. Antidepressantsare not without consequences; they have many drug-to-drug interactions and can
lead to suicidal thoughts, they are not always a safer choice. Anticonvulsantsare also abused because of euphoric effects and can have serious side effects
like antidepressants. Non-opioid treatments should be considered, but the
effects of alternate drugs should not be undermined.

·“Calculate opioid
dosage morphine milligram equivalent (MME).” Every patient is different. It is
common sense to taper any drug or treatment to effect, but this particular
issue could put a prescribing physician at risk of litigation. (See Dr. Fudin's opinions.)

There are many things I agree
with, some that I can tolerate, and others that I felt needed attention. The
NPS did have representation by advocates during its draft, and we have all been
waiting for it to be released. And, so it has been. You can see and overview
and download the National Pain Strategy here.

“The Strategy
provides opportunities for reducing the need for and over-reliance on prescription
opioid medications;” this statement disturbs me. I believe the only way we can reduce the need
for pain relief is to find a cure for scleroderma, complex regional pain
syndrome, the effects of aging on the body, arthritis, fibromyalgia, EDS, myofascial
pain syndrome, the centralization of pain, etc. Relieving pain is instinctive
to all animals, including humans.

Not including all
the stakeholders in the drafting of the CDC guidelines has many advocates and advocacy groups
incensed, and rightly so. Public notice of the guidelines was made public for only 3 days. Only after being
caught, did they allow our voice. But, despite pleas made by people far better equipped and knowledgeable (and unlike me, able to retain what they read), the CDC published them anyway. The total disregard for our government process - by, with, and for the people - is deplorable.

The CDC guidelines could have
been done much better and would have been better received if our voices had
been heard. And, it bothers me that the NPS overview ends with this statement, The
goals of the National Pain Strategy can be achieved through a broad effort in
which better pain care is provided, along with safer prescribing practices,
such as those recommended in the recently released CDC Guideline for Prescribing Opioids for Chronic Pain. I doubt
many of those who helped draft the NPS were aware of these guidelines being drafted when they participated in the drafting of the NPS. Some of those same people are among those who tried to hold the CDC
accountable for their lack of transparency. (Read about it in The Guardian.) The CDC Opioid Prescribing Guidelines
are not all bad, but they are written with a discriminatory tone, which is
counter-productive to the Institute of Medicine’s report, Relieving Pain in
America, available from my website here.

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